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Non-Union for Orthopaedic Exams
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Non-Union for Orthopaedic Exams
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Language: EN.
Segment:0 .
Everyone, sorry about the technical problem will start promptly now. Our this week's teaching Szechuan is presenting on a nice topic of non-union. Very important if our case question. So you're all invited to listen. And please put your questions in chat option. This will be followed by hot seat sessions, so please express start expressing your interest.
From now, Sydney messages over to issue one. Hello, everyone. Thank you for joining us today. I want to thank you for us and our mentor groups for continuing to make this possibility. I'm just going to share the screen. We've got a PowerPoint presentation coming up. Here we go. So I presume everyone can see us go to present screen.
So today's topic is about how to approach a non-union exam. This is not a complete answer. This is not a tutorial on unions and all possibilities of non-union. This is all about how to approach. I would like to state that, first of all, everything I say in this is my opinion, and it's not affiliated to any group, and this presentation is not affiliated to any group apart from our overseas mentor group.
The first thing to say to you is this is the picture, you will receive in the exam or something accordingly. And what do you do, doctor? What do you think? First of all, don't panic. Don't start saying who mess this up and don't start crying and breaking down about this. It's an easy question. You just need the system to get through it.
So first of all, you need to say, stay calm. Describe what you see. So for example, in this x ray, in this radiograph, I'll say lateral radiograph of distal femur with a short retrograde nail inserted for a distal thermal fracture on what looks like in this view, a well, fixed total prosthesis concerning me here is the hypertrophic on traffic and traffic nonunion.
If you don't know the definitions of either and to be able to describe what you're seeing straight away now, you have time, you've got your opening sentence, you relaxed, you're getting ready to talk about your pathway. But don't forget to ask for overviews and full length, you need to know the full story of this patient before you jump in and say, wow, that was a very short nail. So the reason why this failed was because of the surgeon putting in the wrong nail or something like that.
Naturally, you're not going to see position here, but I just showing you all the possibilities that you could have that would give you a reason why you would think suboptimal fixation might have occurred. OK but always remember you're not sitting in the radiology radiology exam. What do you see is the opening question in your exam? It doesn't carry any marks.
It's just to get you comfortable and get you on to the substance and get to the substance. And please, you all live in glass houses. Don't criticize the previous surgeon. You don't know the circumstances of the reason why it happened. Was this a bailout option? Was there problems associated with the patient? Was there multiple injuries? You don't know the full story, so don't criticize the surgeon in the middle of the exam.
OK, so question will be what do you think or what would you do or what is a nonunion? So I would define a non-union as a fracture, which has passed the expected time to heal and showing no signs of progression. Non non unions have multiple causes and often maybe multifactorial, and my management will be guided according to the causes which I would divide into infection local factors, systemic factors and mechanics.
Simple get out of jail sentences. Get you into the flow of the discussion. Memorize them and use them. OK, so infection nonunion should be considered, in fact. And so any non union should be considered infected until proven otherwise. What will help you decide is the history the chronology of events was there presence of scientists on the examination and the presence of scar primary versus secondary?
Don't get into the habit of asking the examiner. The question was, is there a sign? Is there a scar? So I presume there is no. The scar is by primary intention with no evidence of any sinus, and history and examination has no suspicion for infection. However, I would like to rule infection, blood markers, cultures. When you do mention cultures do talk about tissue samples because that has been shown to be the most accurate, as opposed to a simple aspirating the sinus or anything like that.
Take bone or soft tissue samples. Next to the Bowl. Radionuclide scanning, labeled leukocyte scanning and MRI are all options. Their sensitivity and specificity vary between different papers. The most sensitive is MRI scan. However, it can be a false positive, and the most sensitive and specific is labeled leukocyte scans.
However, the problem associated with them is that they are very good at picking up acute infection. But in chronic low rumbling infections, they're very poor. And then I've just left the table there for you guys to pursue later on about the leader classification system, which divides anatomic type of physiological class and helps you develop a management plan for these patients if this is where the question is going. Moving on to local remember, you don't have a lot of time to be talking about every part of this, so just make sure you get your headings in first so that the examiners know where you're going.
Local includes index injury, fracture personality, energy stability, muscularity and location of the fracture within the bone. So if it's a typical day of ACL, it's a higher risk of money in universities. For example, a metaphyseal tibia, open fracture compartment syndrome, soft tissue stripping either preoperative or time and time to surgery are big factors.
In all of this. On the right, you'll see some papers that you can look at these later on when videos on YouTube. The first group of papers are all about the Costello Anderson classification system and the risk associated with nonunion. Blair et Al. Showed that compartment syndrome is a good predictor for nonunion as well, and to Sharon and to Sharon's classification system for soft tissue injuries without an open fracture, which often indicates a severe vascular injury to the soft tissues.
Surgical techniques is the second part of the local tissue handling tourniquet time wound coverage. All of these things matter Remmers and their use without saline or fluids to decrease the risk of heat osteonecrosis. The inappropriate use of the structures and external fixtures, which potentially need to be aware, can strip tissue if you over distract and your approach can decide if you're going to damage the soft tissues around the bone as well.
My philosophy on any fracture is. A fracture is a soft tissue injury with a bone in it. Literally remember to look after the soft tissues, because revascularization of ischemic bone fragments is all about the soft tissues, it all comes from the soft tissues. If you can preserve soft tissues, you're likely to have preserved bone.
And your approach as well. So your appropriate application of fixation devices and cast at the time of surgery. OK systemic issues include the patient comorbidities such as diabetes, COPD, peripheral vascular disease, steroid use immunosuppressants, endocrine disease with thyroid and parathyroid problems, and vitamin D and vitamin K with no vitamin D on its own is not enough to ensure a patient.
A normal vitamin D on its own is not enough. Patient needs to have vitamin K to help them metabolize their vitamin D patients. Patients social factors such as smoking, alcohol, other drugs marijuana use has been shown to stop bone dead and patients compliance issues. Patient has a history of psychiatric illness or not able to comply with no bearing plan that you had developed.
Looking at an X-ray or a patient's personal circumstances doesn't allow them to come frequently enough, for example, to keep an eye on the wound while you're treating with an external fixator and then mechanics. So in the mechanics part, I could spend a long time explaining to you all about the biomechanics, but we'll do another presentation about biomechanics and how to establish healing.
But remember, when you're talking about mechanics for nonunion, you need to establish three questions. What was the principle attempted? Was was an appropriate principle for the factual configuration. And was it achieved the. So, for example, in an anatomical reduction in absolute stability, where you want primary healing, these are usually for intracranial fractures.
Simple to seal fractures the while relative stability, which uses bridging principles, you need relative secondary healing. And again, you need to establish what is the most appropriate fixation principle that you want for this fracture. And then what tools would you use to do this? And if that is, if they have used the same tools, was their initial plan achieved?
If not, where was the problem? If you establish all of this, you can probably establish the issue behind the problem and then we get to Management. So now at this point, you have said there are local factors, surgical factors and mechanical factors. You've already said I've wound infection. Now you're going to get on to the management.
Now, unfortunately, this is not something I can answer to you straightaway, and we'll get plenty of opportunities later on in the hot seat to discuss management of the different variations of presentation. But I would use key words. This is a difficult problem. It recognizes that you have experience with this or recognize that this is not an easy problem you're going to use to assess, cause and address the causes.
That's the most important part in developing your management plan. So you notice I put s in pool because they could tell you this patient is a diabetic with this X-ray. Or it could tell you that there is a patient, is a heavy drinker and so on. So you need to establish how you're going to address individual causes, both systemic, local and patient factors.
OK, describe this. I would use definitely use terms like mdc-t approach. I would consult with my bone infection unit discussed with my reconstruction surgeon, discuss with the medical team that are looking after this patient's x, y and z. Discuss the social issues involved, social workers and/or Allied health professionals in your development of your management plan.
And don't hesitate to say you would confer with colleagues who have more experience. However, that prompts the next question doctor, what are you going to do or what will they say they will do? So you still need to develop your plan accordingly. But giving an overall approach to this and moving quickly through this will allow you to get on to discussing where the meat of the question is, for example, is it is this question all about infection?
Is it about mechanics? Is it about primary versus secondary healing, safely managing the complex case? It could be about bone grafting, and I've put in lots of letters in there to say it could be anything. The question can go in any direction they wish it to go. But take your cue from the examiner and don't get yourself into difficulty by going into fine details.
Trust me, staying the basics. Keep it simple. So in conclusion, don't panic. Keep it simple. Develop your structure and answer accordingly, you can tweak this answer to pretty much any scenario. Examples would be tell me the factors that lead to non-union. What are the principles of healing? How can you decrease risk of nonunion?
What factors lead to infection and trauma? Why does this not heal? Literally, every topic comes up in those type of questions again and again. Understanding the biomechanics will come to that, hopefully next week or the week after. I'll have another presentation for you guys explaining how we can deal with the principles of too much rigidity or too little rigidity and so on.
OK is there any questions? No, I think there has not been any questions. I think it's was very clear presentation one as it were, and I urge everyone to review this presentation again when the recording is sent because it contains, in my opinion. Everything you need to know for it to answer this question perfectly and your Viva station.
Um, I like the definition that you can give for nonunion. I've seen some situations when examiners insist on the candidate a little bit more on what happened. Can you give me a timeline? Is it 3 months? Is it four months? And I think it is. I would insist on not giving a timeline. Um, and it is all a combination of radiological and clinical factors or clinical signs so insistent those I would look for radiological and clinical signs of nonunion.
But there is the FDA definition. The FDA has defined nonunion as absence of bone progressive bone union of a long bone only. They only define that for long bone for a period of four to six months after four to six months. So even really free stuck. And you have to give a number to examine a mention that fda? No but.
So for example, the problem associated with nonunion is that you have to be very careful if an examiner is pressing you for a month that I agree with for how many months is a union? It depends on your fracture type, depends on what bone is affected and which parts of the long bone, the tibia. You do expect to take longer than, for example, a femur. And then the consequences of a nonunion are far greater in the patient.
For example, with a femur fracture where you've nailed, where you can have a race between the bone healing and the metal where failing. OK so make those issues clear to the examiner that this is if you're not seeing progress about a certain time, you're worried about failure of metal where before hip fracture healing? OK, great.
And we have a question, Shawn. About the role of bone marrow injection. Are you aware of anything? So there is quite a number of papers involved in all of this. So the problem is you can quote, As many papers as you like, and that's fine. Go right ahead. But what you'll find is that you will know your paper well and discuss the use of a different bone.
Sorry bone marrow or bone more allogeneic protein or bone graft? Just be aware. The only thing not to get yourself trapped into is don't put good, healthy bone, even if it's dead into infected bone. That's be careful because you're now going to the aid question and you've forgotten this patient is infected and you start talking about bone grafting and so on.
OK your papers. I don't need to give you quotes. There's lots of them. And if you can know if a paper, feel free to quote it, but I wouldn't. I wouldn't give you one offhand. Sure and another question about the use of excision, and I think in the exam try not to suggest this slightly controversial issue, but if the examiners ask you and I think excision.
It is it is in the NICE guidelines of management of nonunion, not the device, but I think so there's a nice review on oxygen and the union. If you want to read it, use it. But if you're going to bring it up, you need to know that NICE guidance very well. However, I would say to you, if you're going to talk about an oxygen ultrasound, then you need to know why you're using this.
Again, be very careful. Stick to the principles of your management. You're a surgeon. Understand that there are infection. Local factors, systemic factors, surgical and mechanical factors address those issues. Don't use your oxygen as your bailout thing for every scenario because the question is not about oxygen. The question is going to be about is going to be about, do you understand what causes nonunion and how to deal with it?
Yeah, I think if the nice guidelines, you could mention them at the end. After you've mentioned everything she once said, you could mention them and then you will be you'll be quoting literature because there has NICE guidelines for nonunion after nine months of long bones only. So unless all these specific details, as after nine months and after four long bones only, then otherwise don't mention it.
So if you're not very sure about it, don't mention it. But, but yeah, it has a role in the management who some would like to say anything. We have some here. One of our mentors is kind of joined us. Would you like? Thank you for us. I think she covered well from while he was running the slides.
The only thing again, as always, Shawn is saying. And everybody saying, keep it simple, it's just it's about that. You know, what the non-union means, what should come to your mind? It is like in the revision of the hip or socializes or pain in the hip. It is infection, it's infection. So everybody he wants you to think infection at first and then go on after that.
And as long as you are keeping with the principles and going step by step with the timing, with following up, maybe CT if you are not sure about all this, what we are doing daily in our practice, but don't go into the ultrasound and everything because he will catch you over there, he will catch you over there. So just keep it simple and five minutes to really, really short pants.
The presentation I just did took more than five minutes, and that's just getting that information across you guys. You need to be able to get that information across to the examiners as well in the fluids and simple way. Exactly I mean, that's the whole idea. It's a short, crisp presentation that can't get everything they need to know. They have only five minutes in the exam, so it's not about present or not talking a lot, having a massive amount of knowledge about presenting your answer specifically.
So in the exam situation, nonunion always think of infection and mechanical, and it depends on where station you are sitting in. If you're sitting in the basic sciences station, it could be leading you towards mechanical factors, and examiners want to discuss biomechanics of fracture fixation and stuff like this. So if you felt it's going that way, if you've seen a plate failed, for example, or a nail has failed, please straightaway get into that discussion of biomechanics.
Don't waste a lot of time on other issues. So just take take, take your cue from the examiner because if the examiner says there's no sign of infection or all the results are negative for infection, don't start beating the examiners with I'm going to look for infection, I'm going to look for infection histology. There's no infection. The topic is somewhere else.
The marking is somewhere else. Yeah, Yeah. We see that all the time. We see that all the time. Yeah, if the examiner, if it'll tell the examiner, I want to rule out infection and that's it, exam, I will tell you there are no signs of infection. Move on. Don't keep saying, oh, I want to do a CRP.
What's his cerp? What's his? Yeah, exactly. I got a question like the fracture of the femur and it has been treated with nail and fade. And then we all the discussion was about, OK, why it is failed. So we I talked about the first rule out the infection, then it's about the short segment and it's about the working lens and also.
Tape of the host and all these things, and then because it is, it was actually protruding to the knee. And then what's the next step. And what we're going to do? And then we talked about OK plating first, and I talked about how the plate. And again about the spreading of the screws and so the stresses would be distributed. And then after this heals, I will go forward.
Totally So it was about everything thinking about the patient from the beginning until even the next step. What are you going to do to get the patient to the best status to treat him or treat her at that time? I'm not sure what is. Where was the question again? It is Nadeem from Nadeem. Is the exclusion after the oxygen one?
How so could you repeat the question again, just so I can understand it? How should you find out? Necrotic segment in infected nonunion so necrotic segment is based on the definitions of when you're looking at the X-ray sequester. Piece of bone is essentially a necrotic segment, any part which has no vascular and what is the definition of vascular?
The a bone, a bone, which is not in continuation with the other bone and/or has no soft tissue connection either. And so if you are doing a development as well, any bone, which is not bleeding is considered necrotic segment in the infection. OK, that's great. Thank you. Thank you, Sean.
I think most people are very keen to get on with the hot seat session. And I think we answered all the questions. It's a great presentation, but you had. 36 participants. Which is great Thanks to everyone who attended this session now, and I will send another invitation in 2 minutes only for the hot seat session, so far I have three candidates who expressed interest and will go in an order.
We have.
Segment:0 .
Everyone, sorry about the technical problem will start promptly now. Our this week's teaching Szechuan is presenting on a nice topic of non-union. Very important if our case question. So you're all invited to listen. And please put your questions in chat option. This will be followed by hot seat sessions, so please express start expressing your interest.
From now, Sydney messages over to issue one. Hello, everyone. Thank you for joining us today. I want to thank you for us and our mentor groups for continuing to make this possibility. I'm just going to share the screen. We've got a PowerPoint presentation coming up. Here we go. So I presume everyone can see us go to present screen.
So today's topic is about how to approach a non-union exam. This is not a complete answer. This is not a tutorial on unions and all possibilities of non-union. This is all about how to approach. I would like to state that, first of all, everything I say in this is my opinion, and it's not affiliated to any group, and this presentation is not affiliated to any group apart from our overseas mentor group.
The first thing to say to you is this is the picture, you will receive in the exam or something accordingly. And what do you do, doctor? What do you think? First of all, don't panic. Don't start saying who mess this up and don't start crying and breaking down about this. It's an easy question. You just need the system to get through it.
So first of all, you need to say, stay calm. Describe what you see. So for example, in this x ray, in this radiograph, I'll say lateral radiograph of distal femur with a short retrograde nail inserted for a distal thermal fracture on what looks like in this view, a well, fixed total prosthesis concerning me here is the hypertrophic on traffic and traffic nonunion.
If you don't know the definitions of either and to be able to describe what you're seeing straight away now, you have time, you've got your opening sentence, you relaxed, you're getting ready to talk about your pathway. But don't forget to ask for overviews and full length, you need to know the full story of this patient before you jump in and say, wow, that was a very short nail. So the reason why this failed was because of the surgeon putting in the wrong nail or something like that.
Naturally, you're not going to see position here, but I just showing you all the possibilities that you could have that would give you a reason why you would think suboptimal fixation might have occurred. OK but always remember you're not sitting in the radiology radiology exam. What do you see is the opening question in your exam? It doesn't carry any marks.
It's just to get you comfortable and get you on to the substance and get to the substance. And please, you all live in glass houses. Don't criticize the previous surgeon. You don't know the circumstances of the reason why it happened. Was this a bailout option? Was there problems associated with the patient? Was there multiple injuries? You don't know the full story, so don't criticize the surgeon in the middle of the exam.
OK, so question will be what do you think or what would you do or what is a nonunion? So I would define a non-union as a fracture, which has passed the expected time to heal and showing no signs of progression. Non non unions have multiple causes and often maybe multifactorial, and my management will be guided according to the causes which I would divide into infection local factors, systemic factors and mechanics.
Simple get out of jail sentences. Get you into the flow of the discussion. Memorize them and use them. OK, so infection nonunion should be considered, in fact. And so any non union should be considered infected until proven otherwise. What will help you decide is the history the chronology of events was there presence of scientists on the examination and the presence of scar primary versus secondary?
Don't get into the habit of asking the examiner. The question was, is there a sign? Is there a scar? So I presume there is no. The scar is by primary intention with no evidence of any sinus, and history and examination has no suspicion for infection. However, I would like to rule infection, blood markers, cultures. When you do mention cultures do talk about tissue samples because that has been shown to be the most accurate, as opposed to a simple aspirating the sinus or anything like that.
Take bone or soft tissue samples. Next to the Bowl. Radionuclide scanning, labeled leukocyte scanning and MRI are all options. Their sensitivity and specificity vary between different papers. The most sensitive is MRI scan. However, it can be a false positive, and the most sensitive and specific is labeled leukocyte scans.
However, the problem associated with them is that they are very good at picking up acute infection. But in chronic low rumbling infections, they're very poor. And then I've just left the table there for you guys to pursue later on about the leader classification system, which divides anatomic type of physiological class and helps you develop a management plan for these patients if this is where the question is going. Moving on to local remember, you don't have a lot of time to be talking about every part of this, so just make sure you get your headings in first so that the examiners know where you're going.
Local includes index injury, fracture personality, energy stability, muscularity and location of the fracture within the bone. So if it's a typical day of ACL, it's a higher risk of money in universities. For example, a metaphyseal tibia, open fracture compartment syndrome, soft tissue stripping either preoperative or time and time to surgery are big factors.
In all of this. On the right, you'll see some papers that you can look at these later on when videos on YouTube. The first group of papers are all about the Costello Anderson classification system and the risk associated with nonunion. Blair et Al. Showed that compartment syndrome is a good predictor for nonunion as well, and to Sharon and to Sharon's classification system for soft tissue injuries without an open fracture, which often indicates a severe vascular injury to the soft tissues.
Surgical techniques is the second part of the local tissue handling tourniquet time wound coverage. All of these things matter Remmers and their use without saline or fluids to decrease the risk of heat osteonecrosis. The inappropriate use of the structures and external fixtures, which potentially need to be aware, can strip tissue if you over distract and your approach can decide if you're going to damage the soft tissues around the bone as well.
My philosophy on any fracture is. A fracture is a soft tissue injury with a bone in it. Literally remember to look after the soft tissues, because revascularization of ischemic bone fragments is all about the soft tissues, it all comes from the soft tissues. If you can preserve soft tissues, you're likely to have preserved bone.
And your approach as well. So your appropriate application of fixation devices and cast at the time of surgery. OK systemic issues include the patient comorbidities such as diabetes, COPD, peripheral vascular disease, steroid use immunosuppressants, endocrine disease with thyroid and parathyroid problems, and vitamin D and vitamin K with no vitamin D on its own is not enough to ensure a patient.
A normal vitamin D on its own is not enough. Patient needs to have vitamin K to help them metabolize their vitamin D patients. Patients social factors such as smoking, alcohol, other drugs marijuana use has been shown to stop bone dead and patients compliance issues. Patient has a history of psychiatric illness or not able to comply with no bearing plan that you had developed.
Looking at an X-ray or a patient's personal circumstances doesn't allow them to come frequently enough, for example, to keep an eye on the wound while you're treating with an external fixator and then mechanics. So in the mechanics part, I could spend a long time explaining to you all about the biomechanics, but we'll do another presentation about biomechanics and how to establish healing.
But remember, when you're talking about mechanics for nonunion, you need to establish three questions. What was the principle attempted? Was was an appropriate principle for the factual configuration. And was it achieved the. So, for example, in an anatomical reduction in absolute stability, where you want primary healing, these are usually for intracranial fractures.
Simple to seal fractures the while relative stability, which uses bridging principles, you need relative secondary healing. And again, you need to establish what is the most appropriate fixation principle that you want for this fracture. And then what tools would you use to do this? And if that is, if they have used the same tools, was their initial plan achieved?
If not, where was the problem? If you establish all of this, you can probably establish the issue behind the problem and then we get to Management. So now at this point, you have said there are local factors, surgical factors and mechanical factors. You've already said I've wound infection. Now you're going to get on to the management.
Now, unfortunately, this is not something I can answer to you straightaway, and we'll get plenty of opportunities later on in the hot seat to discuss management of the different variations of presentation. But I would use key words. This is a difficult problem. It recognizes that you have experience with this or recognize that this is not an easy problem you're going to use to assess, cause and address the causes.
That's the most important part in developing your management plan. So you notice I put s in pool because they could tell you this patient is a diabetic with this X-ray. Or it could tell you that there is a patient, is a heavy drinker and so on. So you need to establish how you're going to address individual causes, both systemic, local and patient factors.
OK, describe this. I would use definitely use terms like mdc-t approach. I would consult with my bone infection unit discussed with my reconstruction surgeon, discuss with the medical team that are looking after this patient's x, y and z. Discuss the social issues involved, social workers and/or Allied health professionals in your development of your management plan.
And don't hesitate to say you would confer with colleagues who have more experience. However, that prompts the next question doctor, what are you going to do or what will they say they will do? So you still need to develop your plan accordingly. But giving an overall approach to this and moving quickly through this will allow you to get on to discussing where the meat of the question is, for example, is it is this question all about infection?
Is it about mechanics? Is it about primary versus secondary healing, safely managing the complex case? It could be about bone grafting, and I've put in lots of letters in there to say it could be anything. The question can go in any direction they wish it to go. But take your cue from the examiner and don't get yourself into difficulty by going into fine details.
Trust me, staying the basics. Keep it simple. So in conclusion, don't panic. Keep it simple. Develop your structure and answer accordingly, you can tweak this answer to pretty much any scenario. Examples would be tell me the factors that lead to non-union. What are the principles of healing? How can you decrease risk of nonunion?
What factors lead to infection and trauma? Why does this not heal? Literally, every topic comes up in those type of questions again and again. Understanding the biomechanics will come to that, hopefully next week or the week after. I'll have another presentation for you guys explaining how we can deal with the principles of too much rigidity or too little rigidity and so on.
OK is there any questions? No, I think there has not been any questions. I think it's was very clear presentation one as it were, and I urge everyone to review this presentation again when the recording is sent because it contains, in my opinion. Everything you need to know for it to answer this question perfectly and your Viva station.
Um, I like the definition that you can give for nonunion. I've seen some situations when examiners insist on the candidate a little bit more on what happened. Can you give me a timeline? Is it 3 months? Is it four months? And I think it is. I would insist on not giving a timeline. Um, and it is all a combination of radiological and clinical factors or clinical signs so insistent those I would look for radiological and clinical signs of nonunion.
But there is the FDA definition. The FDA has defined nonunion as absence of bone progressive bone union of a long bone only. They only define that for long bone for a period of four to six months after four to six months. So even really free stuck. And you have to give a number to examine a mention that fda? No but.
So for example, the problem associated with nonunion is that you have to be very careful if an examiner is pressing you for a month that I agree with for how many months is a union? It depends on your fracture type, depends on what bone is affected and which parts of the long bone, the tibia. You do expect to take longer than, for example, a femur. And then the consequences of a nonunion are far greater in the patient.
For example, with a femur fracture where you've nailed, where you can have a race between the bone healing and the metal where failing. OK so make those issues clear to the examiner that this is if you're not seeing progress about a certain time, you're worried about failure of metal where before hip fracture healing? OK, great.
And we have a question, Shawn. About the role of bone marrow injection. Are you aware of anything? So there is quite a number of papers involved in all of this. So the problem is you can quote, As many papers as you like, and that's fine. Go right ahead. But what you'll find is that you will know your paper well and discuss the use of a different bone.
Sorry bone marrow or bone more allogeneic protein or bone graft? Just be aware. The only thing not to get yourself trapped into is don't put good, healthy bone, even if it's dead into infected bone. That's be careful because you're now going to the aid question and you've forgotten this patient is infected and you start talking about bone grafting and so on.
OK your papers. I don't need to give you quotes. There's lots of them. And if you can know if a paper, feel free to quote it, but I wouldn't. I wouldn't give you one offhand. Sure and another question about the use of excision, and I think in the exam try not to suggest this slightly controversial issue, but if the examiners ask you and I think excision.
It is it is in the NICE guidelines of management of nonunion, not the device, but I think so there's a nice review on oxygen and the union. If you want to read it, use it. But if you're going to bring it up, you need to know that NICE guidance very well. However, I would say to you, if you're going to talk about an oxygen ultrasound, then you need to know why you're using this.
Again, be very careful. Stick to the principles of your management. You're a surgeon. Understand that there are infection. Local factors, systemic factors, surgical and mechanical factors address those issues. Don't use your oxygen as your bailout thing for every scenario because the question is not about oxygen. The question is going to be about is going to be about, do you understand what causes nonunion and how to deal with it?
Yeah, I think if the nice guidelines, you could mention them at the end. After you've mentioned everything she once said, you could mention them and then you will be you'll be quoting literature because there has NICE guidelines for nonunion after nine months of long bones only. So unless all these specific details, as after nine months and after four long bones only, then otherwise don't mention it.
So if you're not very sure about it, don't mention it. But, but yeah, it has a role in the management who some would like to say anything. We have some here. One of our mentors is kind of joined us. Would you like? Thank you for us. I think she covered well from while he was running the slides.
The only thing again, as always, Shawn is saying. And everybody saying, keep it simple, it's just it's about that. You know, what the non-union means, what should come to your mind? It is like in the revision of the hip or socializes or pain in the hip. It is infection, it's infection. So everybody he wants you to think infection at first and then go on after that.
And as long as you are keeping with the principles and going step by step with the timing, with following up, maybe CT if you are not sure about all this, what we are doing daily in our practice, but don't go into the ultrasound and everything because he will catch you over there, he will catch you over there. So just keep it simple and five minutes to really, really short pants.
The presentation I just did took more than five minutes, and that's just getting that information across you guys. You need to be able to get that information across to the examiners as well in the fluids and simple way. Exactly I mean, that's the whole idea. It's a short, crisp presentation that can't get everything they need to know. They have only five minutes in the exam, so it's not about present or not talking a lot, having a massive amount of knowledge about presenting your answer specifically.
So in the exam situation, nonunion always think of infection and mechanical, and it depends on where station you are sitting in. If you're sitting in the basic sciences station, it could be leading you towards mechanical factors, and examiners want to discuss biomechanics of fracture fixation and stuff like this. So if you felt it's going that way, if you've seen a plate failed, for example, or a nail has failed, please straightaway get into that discussion of biomechanics.
Don't waste a lot of time on other issues. So just take take, take your cue from the examiner because if the examiner says there's no sign of infection or all the results are negative for infection, don't start beating the examiners with I'm going to look for infection, I'm going to look for infection histology. There's no infection. The topic is somewhere else.
The marking is somewhere else. Yeah, Yeah. We see that all the time. We see that all the time. Yeah, if the examiner, if it'll tell the examiner, I want to rule out infection and that's it, exam, I will tell you there are no signs of infection. Move on. Don't keep saying, oh, I want to do a CRP.
What's his cerp? What's his? Yeah, exactly. I got a question like the fracture of the femur and it has been treated with nail and fade. And then we all the discussion was about, OK, why it is failed. So we I talked about the first rule out the infection, then it's about the short segment and it's about the working lens and also.
Tape of the host and all these things, and then because it is, it was actually protruding to the knee. And then what's the next step. And what we're going to do? And then we talked about OK plating first, and I talked about how the plate. And again about the spreading of the screws and so the stresses would be distributed. And then after this heals, I will go forward.
Totally So it was about everything thinking about the patient from the beginning until even the next step. What are you going to do to get the patient to the best status to treat him or treat her at that time? I'm not sure what is. Where was the question again? It is Nadeem from Nadeem. Is the exclusion after the oxygen one?
How so could you repeat the question again, just so I can understand it? How should you find out? Necrotic segment in infected nonunion so necrotic segment is based on the definitions of when you're looking at the X-ray sequester. Piece of bone is essentially a necrotic segment, any part which has no vascular and what is the definition of vascular?
The a bone, a bone, which is not in continuation with the other bone and/or has no soft tissue connection either. And so if you are doing a development as well, any bone, which is not bleeding is considered necrotic segment in the infection. OK, that's great. Thank you. Thank you, Sean.
I think most people are very keen to get on with the hot seat session. And I think we answered all the questions. It's a great presentation, but you had. 36 participants. Which is great Thanks to everyone who attended this session now, and I will send another invitation in 2 minutes only for the hot seat session, so far I have three candidates who expressed interest and will go in an order.
We have.
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